Core Recommendations:

Clinical, biochemical and radiological markers of renal bone disease should be monitored regularly

Metabolic acidosis should be corrected

For control of hyperphosphataemia aluminium free phosphate binders should be administered

Vitamin D deficiency should be avoided

Marked hyperparathyroidism should be avoided and PTH levels should be kept at two to three times the upper limit of the normal range in end-stage renal disease

Treatment with growth hormone should not be started in the presence of severe hyperparathyroid bone disease

In case of hypercalcemia, active vitamin D metabolites and calcium-containing phosphate binders should be stopped and dialysate changed to low-calcium solutions.

Parathyroidectomy has to be considered in case of severe, therapy-refractory hyperparathyroidism with radiological signs in combination with hypercalcemia and/or elevated calcium phosphorus product

Comments by evaluators:

This guideline was published in 2006 before rigorous guideline development methodology was defined and systems such as GRADE were available. The guideline is widely quoted and used in many paediatric nephrology centres around Europe. Currently, there is no better evidence to challenge or change these recommendations.

The recommendation on parathyroidectomy may be outdated, as cinacalcet use should be considered before considering surgery.

The discipline/content expertise and the description of the members’ role in the guideline is not always clear.

A treatment regimen, guided by age and vitamin D concentration, for the prevention and treatment of vitamin D deficiency is suggested. An intensive replacement phase followed by a maintenance phase of treatment is recommended

Start vitamin D analogues in the lowest dose to achieve target PTH concentrations and maintain normocalcemia. Subsequent titration of vitamin D therapy may be performed based on trends in serum calcium, phosphate and PTH level.